SRHR service for conflict affected Youths

SRHR situation aggravated by Conflict among AY in Motta town Ethiopia.

Several parts of Ethiopia have been affected by internal conflict, which has been aggravated in the last five years. The recent conflict in the Amhara region has affected schools, health facilities and various public and private institutions. The interruption of school has affected adolescents and youth in the region. While several adolescents and youth are directly affected by the conflict, taking part in the military intervention, a number of other are out of school exposed to forced marriage, gender-based violence including rape. However, as the conflict is ongoing, the extent of damage and impact on adolescents and youth is not well studied and it is exceedingly difficult to support with evidence.

Motta town is in northwest Ethiopia, in the East Gojam Zone of the Amhara Region on the secondary road that links Dejen with Bahir Dar overlooking the Abay River. According to the Central Statistical Agency estimate based on the 2007 national census, this town has an estimated total population of 26,177 of whom 13,331 were male and 12,846 females. Motta town is recently one of the sites heavily affected by the ongoing conflict in Ethiopia. As a result of the conflict, school is closed and several adolescents and youth are either in conflict or in the house being exposed to teenage pregnancy, gender-based violence and other SRHR problems. Most of the schools in the Woreda are not open by the current academic year.

The ministry of Ethiopia has developed a private public mix guide to support private health facilities to ensure access to SRRH interventions in the county. However, the actual engagement of the private sector and its contribution in the expansion of such services is hampered by several factors: lack of capacity building trainings for private health facility staff, lack of access to FP/CAC commodities and the poor linkage between the private facility and the regulatory bodies. Medn medium clinic and Medn Drug store are located in Motta Town and is established by a group of public health and clinical experts managed by Dr. Mahlet, a dedicated female internist who teaches at Wollo University. 

In the past couple of months, we have noted that majority of clients coming to the clinic demand for management of GBV, comprehensive abortion care services including post abortion family planning, comprehensive family planning service (including emergency contraceptives), cervical cancer prevention, and STI management. This number is increasing from time to time as school is being closed following the internal conflict in the area, which made us think of how we can contribute to addressing the SRHR needs of the community through corporate responsibility and linking with partners who have interest to support the SRHR services.

Objectives of the Intervention

• SRHR awareness creation, and referral to services for FP, CAC and GBV services
• Availing an AYH friendly counseling center with Medn Clinic that can provide confidential services.
• Orientation and capacity building of MEDN clinic staff on Comprehensive FP, CAC and GBV services

Major intervention Approaches

Meaningful youth engagement: Identification of adolescent and youth peers and providing a brief orientation of AYH services including FP, CAC and GBV services will be a major approach. Through corporate responsibility, we will orient the clinic staff to provide free counseling and support to organized youth groups. The clinic will also arrange a dedicated room for the youth groups to regularly discuss their SRHR issues and have a youth friendly service with our clinic staff. Youth groups and selected Bajaj drivers will manage the overall facilitation of peer-to-peer education and client referral.

Demand Creation: This project will support adolescents and youth to conduct peer dialogue for demand creation and referral of GBV survivors. This will happen through house-to-house visits, discussion during coffee ceremonies, and using posters and stickers on Bajaj’s to initiate discussions.

Ensuring access to FP/CSAC and GBV services: Access to confidential counseling and service is very critical and is believed to be the best demand creation intervention across the health sector. To ensure this, the clinic will orient and train its staff on comprehensive family planning, safe abortion service and dedicate a separate room for adolescent and youth counseling and service provision. We will also make sure to provide subsidized costs and free services as needed for family planning, safe abortion services and other services for GBV survivors.

[1] Bajaj is a three-wheel vehicle commonly used by the community as a taxi within the town and to nearby rural Kebeles.

Beneficiaries

• Adolescent and youth (age of 10-29): The project will identify and recruit AY at various villages in the town (including the Bajaj Drivers [1]) and provide counseling at individual and small group level about the SRHR services. These trained AY will then be used as change agents to disseminate information in their village about SRHR services, identify GBV servicers and refer clients to the clinic. Indirectly at least 60 AY will be used as change agents who will be expected to reach at least 80 clients each (reaching 4800 AY in total) through their network for SRHR information. At least 25% (1200) of those reached through demand creation will be referred for at least one SRRH services, mainly on access to contraception, and safe abortion services.
• Reproductive age women who are survivors of GBV: Ensuring access to SRHR service for reproductive age women who are victims of GBV is very difficult, as most of them keep silent at home and don’t dare to report to heath facilities. However, we have clients coming to our facility requesting such services and we can use snowball type of client tracing through Women themselves and AY to ensure referral and access to services.

Through our intervention, we will ensure access to SRHR information and services both for adolescents and youth and women of reproductive age. Through ensuring access to contraceptives and comprehensive abortion care services, we will support young girls to avoid unintended pregnancies, address and reduce sexually transmitted diseases including HIV, address morbidity related to unsafe abortion and provide the opportunity for adolescent girls to continue their education and ensure them to have a better life.

• Organizational Structure: Medn medium clinic and Medn Drug store are located in Motta Town and is established by a group of public health and clinical experts managed by Dr. Mahlet, a dedicated female internist who teaches at Wollo University. The facility provides for profit services as well as limited corporate responsibility interventions for those who are not able to pay, which is initiated following the personal motivation of Dr. Mahalet and her colleagues from their experience.

• Local Expertise: Our team is based at Motta, and has an in-depth understanding of the local context, including cultural, social, and healthcare dynamics. This local expertise allows us to tailor our interventions to the specific needs of the community, particularly adolescent girls and young women.
• Healthcare Experience: Dr. Mahlet Balew as an Internist brings substantial experience in healthcare and public health. This experience equips our team with the knowledge and skills required to implement effective SRHR programs and ensure the delivery of quality services. Our funding members also have advanced public health with private and public institutions, and local and international organizations.
• Community Connections: Our team has established connections within the Motta community, including with local organizations, schools, and healthcare providers. These connections enable us to effectively collaborate and leverage existing resources to implement our SRHR initiatives.
• Youth Involvement: Our project places a strong emphasis on engaging young people, including adolescent girls and young women, in decision-making and solution development. We have a dedicated adolescent team member, who are active in youth engagement and are actually the ones who initiated this concept note while they are out of school following the conflict.
• Financial Management: Medn Clinic has a strong financial management where we separately account for corporate responsibility budget and for-profit budgets. Our finance team can handle and will ensure the presence of separate accounts to manage the project fund.

Access to sexual and reproductive health is the last to be prioritized in conflict affected sites. As several adolescents and youth will be out of school; arranged marriage, abduction, and rape are found to increase as evidenced in the norther conflict in Ethiopia. Most women keep silent and gender based violence's are not reported, not linked to services and women continue to suffer the physically and psychologically, may get pregnant due to lack of SRH services; and may continue to carry pregnancy and give birth to a child from their abductor which might also lead to an increased number of street children too. Based on this, our project has prioritized the to apply the following approach which will make it innovative:

Meaningful youth engagement: this project will identify students who are out of school and train them on parent child communication, social problem analysis and reach adolescents and youth peers, and women of reproductive age who are victims of GBV for referral services: FP, CAC and GBV services. 

The use of Bajaj's for demand creation: Bajaj drivers serve the community both on the main road and internal small tributary roads in the villages. this will help them to reach adolescents and youth affected by GBV and ensure them to have access to information and referral.

Social Media: Medn clinic works with IT prforessional from nearby university to design mobile applications, and social medial platforms. We will use these platforms to engage adolescents and youth, provide them a platform to network and interact, and ensure confidential referral of affected clients to the clinic. 

Mobile data collection: Volunteer adolescents and youth will be provided with a mobile based data collection tool designed with Kobotoolbox to collect beneficiaries’ information for baseline study, and evaluation of program interventions.

Mobile short code text messaging: Medn clinic has observed frequent interruption of data service during conflict. To ensure it reaches adolescents and youth with SRH messages, it will register text messaging short code with telecom service providers. This will help the clinic to send messages to customers who agree to receive the texts. On the same note, the clients will have the opportunity to send any questions and ask consultations with the clinic staff. The mobile text messaging will be linked to a computer system and a trained youth counselor will review the messages, and issues that require the attention of the medical professional will be filtered and addressed directly to the sender. 

These interventions will support Medn Clinic to reach hard to reach communities affected by conflict. Moreover, the project will provide an opportunity for adolescents and youth in the locality to engage in identification of their social problem and empower them to be part of the solution. The solution will also have a spillover effect in creating networks for the AY and create a positive image about social media through showing its practical benefits for the youth.

The sustainable development goal 3 envisions a universal health care coverage where everyone can access quality health services. People in conflict affected areas are exposed to several challenges; mainly adolescents, youth and women are predisposed to gender-based violence's which have physical, and psychosocial impacts. Medn Medium clinic is a for-profit private health facility providing service for those who pay for the service. However, through our service in the past more than two years, we have observed the need to provide subsidized services through social responsibility for those who cannot pay. This becomes especially critical in safeguarding vulnerable population groups and individuals, like those affected by conflict. This project will use the following approaches to ensure access to good health and meet the sustainable development goals:

1. Identify hard to reach communities: Gender based violence is usually not reported, especially in conflict affected areas. Our solution will empower victims and ensure them to access SRHR services, addressing leaving no one behind in SRHR services. This will contribute to one of the SDG3 indicators; ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs.

2. Provide subsidized services: One of the barriers to access SRHR services during conflict is lack of financial capability to pay for services. Our service will provide either subsidized or free services on basic SRHR services for AY and women. This will provide financial risk protection and ensure access to quality SRHR services.

3. Reduce morbidity and mortality of AY and women of reproductive age from unsafe abortion and complications that arise from Gender Based violence

According to the international telecommunication union, mobile phone ownership in Ethiopia is about 58%, while about 15% of households have internet access.   Rescent evidence suggests that mobile phone ownership among youth in low-to-middle income countries (LMICs) is steadily increasing. According to a 2014 survey of 24 emerging nations, which revealed that between 58% and 95% of people aged 18–29 owned mobile phones. with the expanion of mobile penetration, young people are bombarded with several pieces of information which comes from social media. On the other hand, the media literacy of adolescents and youth require further investment in identifying genuine media sources. Despite the ample opportunities that social media has brought to us, regulation of social media is challenging, and no one can confirm the credibility of the media source and the information dispatched, unless it comes from recognized institutional sites.

Our solution, which targets adolescents and youth mainly in the urban and semi urban  populations of Motta town, has planned to use  Artificial Intelligence and social media tools to empower young people by providing them with accurate Sexual and Reproductive Health and Rights (SRHR) information and access to essential services. This will be supported by IT professionals from nearby universities; Bahirdar and Debre Tabor Universities. The solution planned to be designed by Medn Medium Clinic will apply:

1. Social media supported by AI solutions: Artificial intelligence is becoming a key part of our day to day life, and helping various sectors to innovatively address their problems.  It’s widespread impact is being reflected from entertainment to the workplace, where the health sector is no different. The project will create a social medial platform for adolescent and youth to interact and express their ideas, have peer discussions on SRH, create access to these services, to freely ask any SRHR question to technicians or AI tool with their own preferred language and helps to get quality SRHR guidance even if the health professional is not nearby. Adolescents and youth will be trained and supported to manage social media, counsel their peers and create healthy contents by themselves. Messages disseminated through these social media platforms will be guided by health professionals as per the national and global standards. The social media will also have a chatbot to guide beneficiaries to get specific counseling and guidance on the service they need. 

2. Short code SMS Application: Medn clinic has observed frequent interruption of data service during conflict, and relying on social media for reaching AY might not be enough. Accoridnly, our solution will use short code SMS applications to reach adolescents and youth with SRH messages. Our team will desing the solution to haveWeb based admin summarization for the short code SMS application to 1)  controlling the short code SMS and chat bot for social media, 2) generate messages for chat bot and short code SMS base on client request and 3) give summarized report for the project team to conduct targeted agency building, counseling, referral and service provision.

Artificial intelligence in the health sector has brought opportunities in supporting health workers and patients; through support hem them to identify their medical problem, and guide on prevention and treatment of clinical and public health related health issues. On the other hand, if it is not well regulated, it might also breach clinical data of individual clients, affecting the privacy of patients. At the same time, if the evidence generation is not well designed, it might also lead to wrong interpretation and decisions. 

In this regard, the major concern the project team has identified in this solution is to avoid breach in client information, related to SRHR.Accordingly, primary data access and interpretation of the results from the social media platforms will be critically followed by the project manager. Adolescent and youth peers and social media beneficiaries will also have limited access to individual information, to ensure confidentiality of individual clients in the solutions. Our team will also follow ISO/IEC 27701 -International Organization for standardization rules to keep the clients privacy.  Our team working on AI solutions is aware of compliant with these and other relevant privacy regulations to ensure responsible and ethical use of personal data in AI applications. We will make sure that data will be kept confidential,and the training data will harm no one (not mentioning specific persons while training, inclusivity of women, disabled persons of all races and so on).

This will be discussed and briefed through extensive and transparent health education to individual members joining the group.  The social media platform will also have a Cleary privacy statement indicating the rules and regulation to be followed to ensure data privacy. 

While we try to prevent potential risks from happening, for any breach in client rights following artificial intelligence, we will put mechanism in place to protect the client affected by the solution through an initial advisory group through a tripartite discussion platform; between the clinic, the health office and the medico legal team (local police and judges). 

Through private engagement and use of social media as a positive influencer for people's health behavior, we aim to:

• contribute in the reduction of unintended pregnancy and unsafe abortion following school closure in conflict affected Motta town

• Improve access to contraceptive services among adolescent and youth and

• Contribute to the reduction in morbidity related to gender based violence

• Be a model private facility in providing SRHR services to disadvantaged communities through social responsibility locally, regionally and globally in the next five year

Full time Health Professionals: 

• One internist

• one general practitioner,

• one Health officer,

• two laboratory professionals.

• One pharmacist

Full Time Administrative staff

• one finance officer,

• two cleaner,  and 

• two security guards 

Subtotal full time staff: 11 staffs

Part time Staff

• one radiographer, 

• one dentist; 

• one gynecologist and 

• one midwife nurse

Subtotal Part time staff: 4

Total Staff: 15

Medn Clinic has been initiating a social responsibility activity since its establishment. This was initiated by supporting young adolescents to engage in sports, mainly soccer clubs to build a healthy team. Some of the group members consult the clinic while they encounter medical issues to our clinic staff.

The current conflict in Amhara (in Ethiopia) has left most young people to stay out of school, where several adolescent girls are being forced to have an arranged marriage, rape and exposed to unintended pregnancy and unsafe abortion, which we are committed to contribute and be part of the solution. 

Ethiopia as a nation is committed to addressing equity and quality of health service from the point of Gender, youth and social inclusion. Medn Clinic, as a private sector, is highly committed in ensuring meaningful youth engagement and participation; ensuring gender gaps are addressed and our services are gender responsive. We also recognize and give priority to people with disabilities and hard to reach to have access to our services through creating a social responsibility mechanism.

However, our startup plan and investment is hampered by the current conflict and cost inflation in the market which challenges the purchasing power of the local community and net profit of the organization to invest on its social responsibility. We hope such projects will provide us the opportunity to support our beneficiaries and meet our professional and organizational vision.

According to the 2019 global financing facility private sector assessment in Ethiopia, only 27% of the health facilities in Ethiopia are owned by the private sector, which makes the Ethiopian private sector to be small and fragmented (covering only 205 of the total market share) compared to other countries. On a similar note, the engagement of the private sector in contribution to social development is very minimal. Noticing this gap, the Ministry of Health in Ethiopia has developed a private public mix guideline which provides the opportunity and support for the private sector to engage in providing access to SRHR services, family planning, adolescent and youth health, safe abortion care services and sexually transmitted infections.

Medn Clinic, in this regard also feels the potential that the private health facilities can play in reaching the disadvantaged communities in the country. Our solution in this context is designed to use the existing private infrastructure, human resource, and diagnostic and medical facilities through social responsibility to contribute to addressing the SRHR needs of the community in conflict affected Motta Town. We hope, this opportunity will support us in building our internal capacity in terms of project management and implementation to reach our planned deliverables. Our team is very committed and staffed with youth professionals to contribute to.

While executing this project, Medn clinic plans to engage and partner with the local health offices, adolescent and youth and nearby private clinics to expand access to SRHR services. Through this engagement, we also plan to mobilize internal resources and build the culture of private engagement in addressing public health issues in the implementation site.

We are a private for profit organization and we ensure that our services generate reasonable income to ensure the continuity of our clinical and community activities. While most of the clinical interventions are for those who are able to pay, we feel we also have the responsibility to reach and serve those who are disadvantaged. This will be supported through our social responsibility fund which will be further strengthened and through such projects that the team designs and implements.

Medn clinic is established with a baseline Capital cost of about 108,254.55 USD. To ensure the functioning of the clinic intervention, Medn Clinic currently  runs about 15,303.27 USD for community activities including subsidized clinical services, 79,418.18  USD for human resource, 74,181.82  USD for running medical supplies and reagents (including drugs) and  20,756.36 USD for admin and utility costs.

The solution we propose  will have a very limited human resource budget and capital resources as it will use existing office and human resource capitals in the clinic. Medn Clinic will charge only a level of effort for specific project personnel and admin related costs. However, we will engage adolescents and youths as interns, purchase medical supplies to support the provision of SRHR services for the disadvantaged communities and develop social media platforms with our IT team. This will totally require a 91,447.27 USD budget for one year implementation. The details of our costing indicate 50,981.82 USD for activity costs, 14,487.27 USD for subsidized clinical and medical diagnostic costs, 8,072.73  for human resource mainly level of effort, and 17,905.45  USD for admin and utilities (including communication, electric and water bills, vehicle rental and fuel costs). Please note that we can provide the details of the budget calculation as required at any time.

Medn clinic is committed in ensuring availability and access to quality medical investigations and clinical services to rural and semi urban communities in Ethiopia, who require travelling long distances in search of referral facilities and medical investigations. However, during the last couple of years, our team has learned that financial barriers are one of the challenges to ensure access to such services for the most disadvantaged parts of the community.

In this regard, social responsibility is very critical and the engagement of the private sector in availing basic preventive and health promotive services would support in building a healthy community and contribute to the achievement of the sustainable development goals that the country has already committed; ensuring no one is left behind to access essential primary health care services.

To ensure that Medn clinic achieves its mission and goal to contribute access to primary health care services; we believe that all the opportunities that Cure Residency has brought are unbelievably valuable to the private sector. However, accessing seed funding, mentorship and networking are the critical gaps in the private sector and we would prioritize the three of them, seed funding, mentorship, and networking at this point.